Um Nurse

Company:
AHI agilon health, inc.

**Location**:
Remote - HI

Job Title:
UM Nurse

**Job Description**:
Position Summary:
Responsible for the coordination of services for hospitalized patients and the facilitation of a person-centered, safe, efficient and effective care transition.

These activities include but are not limited to: treatment planning, evaluation of progress, documentation, and facilitation of discharge planning in accordance with agilon’s policies and procedures. Maintains ongoing patient communications with the Medical Directors, Hospitalists, and Case Managers as appropriate needed.

Essential Job Functions:

- Follows all agilon health policies and procedures, including but not limited to personnel policies, safety policies, and operational policies as communicated by management.
- Follows all medical management policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements, and performance requirements as communicated by management.
- In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member, and client information as specified by agilon health.
- Represents agilon health in a professional manner when dealing with both internal and external customers.
- Effectively manage hospitalized patients either telephonically or onsite to ensure that appropriate discharge plans are developed and implemented
- Reviews the patient’s medical, functional and social needs and identifies patient risks for consideration in the prevention of readmission
- Initiates discharge planning within twenty-four hours (24 hours) of admission
- Develops a comprehensive Discharge Plan and Handoff to the Outpatient High Intensity Case Management team.
- Communicates with hospitalist and other care team members to gather clinical information through verbal and written communications, and provides timely and accurate responses to requested information
- Actively participates in weekly rounds. Present current patient information to facilitate discussion of discharge plans and continuity of care needs.
- Refers cases to the Medical Director, Utilization Management when the treatment request does not meet medical necessity guidelines or when peer-to-peer conversation is necessary.
- Makes referrals to the Medical Director, Utilization Management in a timely manner, to allow time to make appropriate contact with the requesting provider is accordance with State, Federal, Regulatory, and accreditation turnaround times.
- Maintains a thorough understanding of NCQA, URAC, and CMS guidelines for Utilization Management.
- Communicates with members of the Utilization and Care Management team, reviews medical records, uses clinical expertise, and compares information to established guidelines and the member’s benefit plan.
- Identifies problems or complex cases and refers for possible Care Management intervention and identifies members with chronic disease process for possible disease management intervention.
- Coordinates the delivery of cost-effective, quality-based health care services for members.
- Assists with the set up and approval of skilled nursing facility or rehabilitation facility per established protocol.
- Assists with the set up and approval of Home Health Care or Durable Medical Equipment upon discharge from hospital per established protocol.
- Maintains thorough understanding of the Health Plan’s provider contracts, authorization requirements, and MCG.
- Reviews authorization requests and communicates with the physician’s offices when additional information is needed or assists office in re-directing care to an appropriate plan provider or facility.
- Conveys and records authorizations clearly within the notes; completes all necessary paperwork and approves or refers to Medical Director, Utilization Management potential denials and comments in the system per established protocol.
- Other duties, as assigned.

Other Job Functions:

- Understand, adhere to, and implement the Company’s policies and procedures.
- Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
- Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
- Engage in excellent communication which includes listening attentively and speaking professionally.
- Set and complete challenging goals.
- Demonstrate attention to detail and accuracy in work product.

Required Qualifications:
Minimum Experience
- 3+ years of experience clinical experience in an acute care facility or equivalent combination of education and experience
- Experience working in Managed Care
- Payor experience and/or experience with nationally recognized clinical criteria, including MCG

Education/Licensure:

- Graduate of an approved nursing prog